This paper details the prevalence of IDU and HIV, the availability of HIV treatment (ART) and harm reduction (NSP/OST) services across 21 countries with either high or emerging HIV epidemics among PWID, and efforts to scale up service coverage to PWID. The increasing rates of IDU and HIV among IDU remain concerning. Varying rates of HIV prevalence among PWID and varying levels of HIV treatment and harm reduction service coverage have been noted.
First, this study found that countries surveyed vary with regards to IDU trends, with some having a very high prevalence of IDU, while it is an emerging trend in others. Specifically, across the 21 countries surveyed, the Russian Federation and the Ukraine are the countries with the highest prevalence of IDU, while most African countries have comparatively lower proportions of PWID. Despite this, IDU is a cause for concern in African countries, which already have generalized HIV epidemics. Failure to address IDU and HIV risk among PWID in this region will impact negatively on efforts to prevent new HIV infections and curtail the epidemic. Between one fifth and a quarter of PWID across the selected countries are living with HIV. The average proportion of PWID who are HIV positive is just under 22% across the 19 countries where data were available.
Second, the paper also highlights the poor coverage of ART services for PWID, across the 21 countries. The proportion of PWID who are HIV positive and who receive ART is very low (less than 12% with the exception of Bangladesh). This could be because they are still healthy (CD4 counts that are still high), however, this information is lacking and in light of recent reports , it is more likely that it is because of barriers to accessing ART for PWID. The lack of updated data with regards to IDU and HIV services to PWID is a matter of concern for many of the 21 countries. A large number of countries with high prevalence rates of HIV among PWID are not aware of the proportion of HIV positive PWID who are receiving ART. This is a major concern as ART use can help decrease risk of transmission among PWID and also their sexual partners. Data on ART service coverage disaggregated by IDU is increasingly necessary, especially in countries with a high prevalence of HIV among IDU, but also for countries where IDU is an emerging problem. This data could serve as a baseline for informing the development, implementation and scaling up of HIV treatment services for PWID.
Third, we noted that these 21 countries also vary in the extent to which they provide harm reduction services to PWID, with some countries having established harm reduction services for PWID, and others only beginning to pilot harm reduction programs, due to the rising prevalence of IDU. NSP, in particular, is a fairly new phenomenon in many of the selected countries, with some countries only having one or two pilot NSP sites to date. While most of the selected countries now have NSP available, the extent to which PWID have access to such programmes is questionable. In countries where NSPs are available, only two out of the 21 countries (Kazakhstan and Vietnam) provided medium coverage (between 100-200 syringes per IDU per year), and only two countries provided high coverage (Bangladesh and India). These findings suggest that much more needs to be done to bring these NSPs to scale and help prevent new HIV infections. Barriers to the provision of clean syringes to PWID and uptake of services also need to be addressed in order to improve harm reduction practices.
While many of the selected countries had OST available to PWID, the number of sites per country was low with very few PWID having access to such services. While not all PWID (particularly those injecting amphetamine type stimulants (ATS) require OST, OST coverage still appears to be low (less than 3%) although some exceptions were noted, namely China and Mauritius. A recent report also noted the emergence of amphetamine type stimulants (ATS) in many countries, and the need for harm reduction services for people who inject ATS . This report highlights the lack of information on ATS, as most of the countries do not routinely differentiate between amphetamine and opioid injection. This lack of knowledge affects service planning, as countries have no baseline information that can be used to assess the effectiveness of efforts to scale up services.
The overriding limitation of these data is that data across countries are not collected in a uniform way, with updated information available for some countries only. Eleven of the 21 countries provided data by completing the data collection form, but even for these countries there were many gaps in terms of programmatic evidence, simply because such data are not readily available. And, while the latest progress report on the Global HIV/AIDS response indicates a dramatic improvement in evidence-based HIV prevention, even in this report the ‘evidence’ for many countries is either lacking or fragmented. This data collecting exercise whilst highlighting the lack of specific HIV-related harm reduction services for PWID in some countries, offers a benchmark for improving service coverage in response to emerging injecting trends and rates of HIV.